Professional Documents
Culture Documents
Normal Spontaneous Vaginal Delivery
Normal Spontaneous Vaginal Delivery
Normal Spontaneous Vaginal Delivery
Submitted By:
Amino, Bai Norjanie
Bara, Hussien Jonathan
Lamery, Judy Ann
Lelim, Kevin
Lopez, Jewel Mae
Mala, Samrod
Malicad, Jhazvee
Sepi, Suraida
Temak, Saada
Villalobos, Bai Jehan
BSN 4- DR
TABLE OF CONTENTS
I. Introduction
II. Objectives
*General Objective
* Specific Objectives
III. Patients Data
A. Vital Info
B. Family Background
C. History of Past illness
D. History of Present illness
E. Effects and Expectations of Illness to self and family
F. Growth and Development
IV. Physical Assessment and Review of Systems
V. Definition of Terms
VI. Textbook Discussions
A. Complete Discussion
B. Anatomy and Physiology
C. Etiology and Symptomatology
D. Pathophysiology
VII. Diagnostic Results
VIII. Doctors Order
IX. List of Drugs
X. Drug Study
XI. Prioritized problems
XII. Nursing Care Plan
XIII. Prognosis
XIV. Bibliography
I. INTRODUCTION
This is the case of a female patient, 22 years old, living at Purok Walingwaling, Brgy. Mambucal, South Cotabato. She was admitted last December 12,
2012 at 2:15am at South Cotabato Provincial Hospital and was scheduled for a
delivery under the service of Dra. Weeds. She was diagnosed with Pregnancy
Uterine Full Term 39 1/7 weeks Age of Gestation, Cephalic in Labor G2P0.
Pregnancy starts when a males sperm fertilizes a females ovum (egg),
and the fertilized ovum implants in the lining of the uterus. Because pregnancy
changes a womans normal hormone patterns, one of the first sign of pregnancy
is a missed menstrual period. Normal Labor is defined as the gradual subjugation
and dilatation of the uterine cervix as a result of rhythmic uterine contractions
leading to the expulsion of the products of conception, the delivery of the fetus,
membranes, umbilical cord, and placenta. Labor cannot that be easy: Thereby
implicating that there are process and stages to be undertaken to achieve
spontaneous delivery.
Study shows 7,565 women admitted for labor and delivery in two freestanding charity birth centers that was established in the Philippines. The births
occurred between February 8, 1996, and December 31, 2003. Midwives
conducted all of the deliveries that occurred in the birth centers. The midwives
were certified professional midwives (CPM) or licensed midwives (LM) from the
USA, Canada and the Philippines. They supervised student midwives enrolled in
the Mercy In Action College of Midwifery & Primary Health Care and dualenrolled in the National College of Midwifery's Associate of Science in Midwifery
program. The birthing women were at higher than average risk of a poor
pregnancy outcome because of demographic factors: most were poor, often
malnourished and living in crowded urban slum conditions. Ninety-two percent of
the women and 34% of their spouses were unemployed, and only a little over half
were married. In spite of the poverty, 95% of the women had spontaneous
vaginal birth; 83% had blood loss less than 500 ml; 85% of the babies required
no resuscitation effort; 67% of the labors were without fetal distress or meconium
staining; and 90% of the babies were of normal birth weight. Transfers to a
hospital after admission occurred 7% of the time, with half taking place before
delivery and half after delivery. Neonatal mortality was 4.1 per 1000.
Asking the question of how this condition occurs, this case study will
provide information that may help the readers/listeners understand the cause of
condition. This case study will enhance the knowledge and skills in dealing with
patient who suffers from this condition.
Further complications will be prevented if immediate proper action is
provided and intervention is rendered. Therefore it is important that the health
care provider develop skills in proper management of the client having this
condition.
PATIENTS DATA
A. Vital Information
Patients Name:
Mrs. Seashell
Age:
22 years old
Sex:
Female
Birth Date:
November 11, 1990
Birth Place:
Prk. Waling-waling, Brgy. Mambucal, South Cotabato
Address:
Prk. Waling-waling, Brgy. Mambucal, South Cotabato
Occupation:
Housewife
Tribe:
Ilonggo
Citizenship:
Filipino
Religion:
Roman Catholic
Civil Status:
Single
Educational Attainment:
College Undergraduate (1st year)
Name of Institution:
South Cotabato Provincial Hospital
Date and Time of Admission:
December 12, 2012 @ 2:15 am
Chief Compliant:
Labor Pain
Admitting Diagnosis:
PUFT CIL 39 1/7AOG G2P0
OB history:
LMP: March 5, 2012
Attending Physician:
Dra. Weeds
Spouse Name:
Age:
Educational Attainment:
Occupation:
Parents Name
Fathers Name:
Age:
Occupation:
Educational Attainment:
Mr. Crab
50 years old
Contractual Worker
High School Undergraduate (3rd year)
Mothers Name:
Age:
Occupation:
Educational Attainment:
Mrs. Squid
46 years old
Housewife
College Undergraduate (1st year)
Siblings:
Name
1. Mr. Lobster
2. Mr. Oyster
3. Ms. Clownfish
4. Mr. Whale
5. Mr. Shark
Age
27
24
19
17
11
Educational Attainment
Occupation
High school graduate
Painter
High school graduate
Tricycle Driver
College Graduate (Vocational)
None
College Undergraduate (1 st year)
None
Elementary level (Grade 5)
Student
Source of Information:
Patient
Patients Chart
Source of Medical Financing
PhilHealth
B. FAMILY BACKGROUND
Mrs. Seashell is the third child among the six children of Mr. Crab and Mrs.
Squid; she is an Ilonggo and a Roman Catholic. She belongs to an extended
type of family.
Presently, Mrs. Seashell and her family are residing in their compound at
Prk. Waling-waling, Brgy. Mambucal, South Cotabato with her live-in partner, five
siblings, and her eldest brothers family. Her mother and father have their
separate house in the said compound. Her father is a retired army who is
presently working as a contractual worker at STI Marbel and at the same time
Barangay Kagawad in their place while her mother is a housewife. Her fathers
monthly income is 20,000 pesos which is enough for the needs of their family
which includes only her four siblings who are unmarried. Her eldest brother has a
separate income for his own family. Her five siblings namely, Mr. Lobster, 27
years old male who works as a painter, Mr. Oyster, 24 years old male who is a
tricycle driver, Ms. Clownfish, 19 years old female who finished her 2 year course
of Hotel and Restaurant Services, Mr. Whale, 17 years old male who is a College
level, and Mr. Shark, 11 years old male who is a grade 5 pupil. Mr. Sea Urchin
and Mrs. Seashell have been together for 2 years and they are planning to get
married but they are still saving money for it. Mr. Sea Urchin works as a painter
and his weekly income is 1500 pesos which is sufficient for their basic needs.
According to the patient, their usual diet includes rice, vegetables and fish.
She also said that during her entire pregnancy, she loves to eat fruits such as
papaya and mango. Every morning, she is accompanied by her partner to walk
around their neighborhood as part of her daily exercise and she does the usual
household chores when at home. Their family religion is Roman Catholic so
every Sunday, they attend mass together and after that, they usually eat outside
together. Also, they are encouraged by their father, Mr. Crab, to participate
actively whenever there are activities in their Barangay.
With regards to their family health history, she said that her father was
diagnosed to have hepatitis B and her mother has hypertension. The patient and
her siblings do not have potential health problems. At her father side, both of her
grandparents are still alive but do not have any known disease. Same also with
her mother side. The family experienced common illnesses such as fever, cough,
colds and flu. They utilized over the counter drugs such as paracetamol,
decongestant and pain reliever and sometimes they utilized also herbal
medicines such as lagundi for cough. She added that they do not have any
history or serious or viral diseases in both side of their family. According to her,
they do not have any history of kidney disease or cancer to their family or even
any allergies to foods, drugs, and dust.
C. HISTORY OF PAST ILLNESS
According to the patient she was delivered through normal spontaneous
vaginal delivery by a midwife at their house. She was able to complete her
immunizations which consist of 1 dose of BCG, 3 doses of DPT, 3 doses of OPV,
3 doses of hepatitis B vaccine and 1 dose of anti-measles.
The patient experienced nausea and vomiting in the past few months
especially during her first trimester. She did not undergone blood transfusion and
surgery nor experienced any accidents and denies of having allergies on foods
and any of the drugs.
Her menarche was when she was 12 years of age with irregular
succeeding menstrual cycle. She also experienced common childhood illnesses
such as colds, cough and fever and was treated only with over the counter drugs
depending on the illness experienced, such as biogesic, alaxan, mefenamic, and
neozep. She fails to admit herself for medical check-up in relation to inadequate
financial sources. It was her second pregnancy and her last menstrual period
was March 15, 2012.
As Mrs. Seashell stated, her childhood years she had experienced
diseases such as mumps and chicken pox and other common illness
experienced by a normal child.
D. HISTORY OF PRESENT ILLNESS
Nine months prior to admission, the patient experiences probable signs of
pregnancy like amenorrhea and morning sickness. Upon experiencing this
symptoms, she suspected herself to be pregnant and she decide to buy
pregnancy test kit, she was very happy when she saw it was positive. She
immediately informed Mr. Sea Urchin who was also happy with the result.
According to the patient, sometimes she is irritable, easily get tired, and feels
restless. At the second trimester, she said that she experience regular
contractions and she decided to have a regular pre natal check up. Two weeks
prior to admission, she experienced lightening and vaginal spotting.
At 1:00 in the afternoon of December 11, 2012, she experienced lower
flank pain that radiates at the abdomen and she feels the urge to defecate
associated with irregular interval and prolonged contractions so Mr. Sea Urchin
decided to bring him to their Health Center. At around 2:00 in the morning, they
were referred to South Cotabato Provincial Hospital.
E. EFFECTS AND EXPECTATIONS OF ILLNESS TO SELF AND FAMILY
EFFECTS OF ILLNESS TO SELF
Mrs. Seashell was very happy and she wanted to do everything to give her
full time, love, and care for her second baby.
EFFECTS TO FAMILY
When Mr. Sea Urchin knew that his wife is pregnant he prepares all the
necessary things that would be use for their second baby. He was so happy and
excited and gives all support, love, and care for his wife up to the day of the
delivery of their child.
EXPECTATION TO SELF
Mrs. Seashell expects to deliver her baby with good health and she would
be able to perform her activities of daily living.
EXPECTATION TO FAMILY
The family of Mrs. Seashell especially her partner, Mr. Sea Urchin, expected
that after she delivers the baby normally, she would have a fast recovery.
E. DEVELOPMENTAL DATA
Name of patient: Mrs. Seashell
Age: 22y.o
According to: Ericksons Psychosocial Development Data
Stage of the patient: Young Adult
Theory: Psychosocial Development
Ericksons Psychosocial Development Data
Erickson envisions life as a sequence of levels of achievement. Each stage
signals a task that must be achieved. The resolution of the task can be complete,
partial, or unsuccessful. Erickson believes that greater the task achievement, the
healthier the personality of the person, failure to achieve a task influences the persons
ability to achieve the next task.
YOUNG ADULT (19-40 years old)
STAGE
Intimacy vs.
Isolation
Age:19-40
years old
TASK
Positive: young
adult needs to
form intimate,
loving
relationship with
other people.
Success leads
to strong
relationship
AGE
22
year
s old
JUSTIFICATION
Patient has a lived-in
partner, they lived
together for almost
two years, she got
pregnant in her first
baby but sadly it was
still birth, and now
she try her best to be
a good partner to his
lived-in partner, and
a good mother to her
up coming baby.
Negative:
failure to
achieve it
results in
loneliness and
isolation
Name of patient: Mrs. Seashell
Age: 22y.o
According to: Havighursts Developmental data Task Theory
Stage of the patient: Early Adulthood
Theory: Development task Theory
REMARK
S
Positive
resolution
achieved
tasks
-
Early
adulthood
Age 20-40
years old
Selecting a
mate
Learning to live
with a partner
Starting a family
Rearing children
Managing a
home
Justification
The patient
and her
partner are
not yet
married, they
are just livingin. They had
the chance to
conceive but
sadly it results
to a stillbirth.
Remarks
Partially
Achieved.
JUSTIFICATION
REMARKS
Achieved
successfully
early childhood.
toilet.
Achieved
successfully
Achieved
successfully
Mrs. Seashell
remembered that at this
Achieved
successfully
relationship.
is difficult to achieve.
Achieved
successfully
VITAL SIGNS:
BP: 100/80 mmHg
Temp. 37.1 C
PR: 80 bpm
RR: 24 cpm
Head/ Hair/ Scalp
Inspection: Head is proportional to the body and skull is rounded with symmetrical, flaccid
movement. Hair is black in color and wavy.
Face
Inspection: Facial grimace noted as well as moles noted on some parts of her cheeks.
Eyebrows and eyelashes are equally distributed.
Palpation: No tearing of lacrimal sac during palpation, and smooth.
Ears
Inspection: Ears are symmetrical to the head. No lesions noted, no deformities noted as well
as discharges. Client is able to hear whispered words from 1-3 feet inches. Vibration was heard
equally in both ears.
Palpation: Auricles are mobile, firm and not tender, pinna recoil after it is folded.
Nose
Inspection: External nose are symmetrical, uniform in color and no discharges noted. No
lesions noted. The patient able to smell good and foul odor; air is felt being exhaled through
opposite nares; noiseless.
Palpation: No tenderness and lesions noted upon palpation of maxillary and frontal sinuses.
Lips/ mouth/ teeth/ throat
Inspection: Dry lips noted. Complete set of adult teeth, yellowish in color. The gum is pink in
color, no retraction noted and no gum bleeding noted, the tongues position is in the midline,
pink in color and has white pigment and moves freely.
Neck
Inspection: Jugular veins are not inflamed and no stiffness noted, neck muscles are equal in
size with head is at the center. Smooth, controlled movements.
Palpation: Trachea is in midline position, smooth, firm, and non-tender. Lymph nodes is not
palpable, soft mobile, discrete, and non tender.
Respiratory
Inspection: Intercostals spaces are even and relaxed, chest symmetry are equal, position of
sternum is at the level with the ribs, the position of the trachea is at the level with the ribs.
Palpation: No pain or tenderness noted. Symmetrical expansion of the thorax is noted.
Auscultation: Respiration pattern is even, 24/ cpm. unlabored with a normal breathing pattern.
Cardiovascular
Palpation: No vibrations or pulsations are palpated in the chest area. No masses or tenderness
noted.
Auscultation: Rate is 80 beats per minute. Rhythm is regular. Normal heart sound was heard:
Lab- Dubb.
Breast
Inspection: Nipples are symmetrical to each other, black in color and increase in size. The
areolas on both breast are black in color, milk secretion noted.
Palpation: Tenderness noted due to engorgement.
Abdomen
Inspection: Presence of linea nigra noted. Moles and scars were also noted.
Palpation: Enlargement organs such as liver, and spleen were not noted.
Genitalia
Inspection: Vaginal discharge noted, perineal bulging noted.
Extremities:
Upper:
Inspection: Arms are symmetrical and appropriate to body size, with normal tan skin color. No
swelling noted on both extremities, with IVF number 3 of D5LR 1L at the level of 400 cc and
regulated @ 30gtts/min hooked at left cephalic vein. Hands have equal grasp strength. Fingers
are compute and no deformities noted. Arms, elbows, shoulder are able to move in range of
motion.
Palpations: No tenderness as well as lesions noted.
Lower extremities:
Inspection: Bone structure and bony landmarks are bilaterally symmetrical and equal, joint
structures are symmetrical & equal. Limited R.O.M of the hip, knee ankle, and toes.
Palpation: Non tender, smooth, warm to touch.
Nails, skin
Inspection: ashes noted, fair skin complexion, no lesion noted, short nails and dirty. Impaired
skin integrity noted.
Palpation: skin is warm to touch and has a capillary refill of 2 seconds.
Time: 9:00 am
General:
The patient denies that she does not experienced fever or any common illnesses before the
admission but she claimed that she experienced weight changes and body weakness before
the delivery and fatigue after the labor.
Integumentary System:
Skin: Patient denies of having rashes, lumps, sores and itching of the skin.
Hair: Patient claims that she has dandruff and denies of having head lice.
Nails: Patient denies of having dirty and long nails; nor abnormal growth.
Head: Patient denies of having any head injury and syncope prior to the admission. But the
patient claimed of having headache.
Eyes: Patient denies of having blurry vision, trauma, redness, pain, sore, eyes, glaucoma and
cataracts. She also denies of using eyeglasses.
Ears: Patient denies of hearing loss, pain, infection, discharges and by the use of hearing aid.
She also denies of having impacted cerumen and any ear injury before the admission.
Nose: Patient denies loss of smell, obstruction, injury, and epistaxis but claimed that she
experienced colds.
Mouth and throat: Patient denies of having sore throat, sore tongue and denies also of having
dental carries. Denies also of having hoarseness of voice and gum problems.
Neck: Patient denies goiter and stiffness of neck.
Respiratory System: Patient denies cyanosis, having cough and dyspnea as well as smoking.
Cardiovascular System: Patient denies of having chest pain and palpitations.
Muscoskeletal System: Patient denies joint stiffness but claims weakness, back pain, fatigue
and leg cramps.
Gastrointestinal System: Patient denies of having constipation and bowel irregularity.
Endocrine System: Patient denies of having enlargement of thyroid glands and denies that
she has diabetes.
Female Reproductive System: Patient reported that no deformities about to her vagina.
Breast: Patient denies of having breast sore and lumps.
V. DEFINITION OF TERMS
CERVIX - the lower part of the uterus, opens into the vagina and has a channel that
allows sperm to enter that uterus and menstrual discharge to exit.
FALLOPIAN TUBES are hollow, cylindrical structures that extend 2-3 inches from the
upper edges of the uterus toward the ovaries.
-the end of each tube into a funnel shaped providing a large opening for the egg
to fall when it is unleaned from the ovary.
- it convey the ovum from the ovaries to the uterus and provide a place for
fertilization of the ovum by sperm.
OVARIES the ovaries are small, oval shaped glands that are located on either side of
the uterus. The ovaries produce eggs and hormones.
-produce, mature and discharge ova.
VULVA serves to protect the withdrawal and vaginal opening and is highly sensitive to
touch to increase the females pleasure during sexual intercourse.
MONS PUBIS fatty tissue and skin is covered with pubis after puberty.
-protects the symphysis pubis during sexual intercourse.
LABIA contains sweat and sebaceous glands. After puberty they are covered with
hair.
-protect the vaginal opening. Lubricate the vulva in response to stimulation.
CLITORIS AND PREPUCE clitoris is a small, cylindrical mass of erectile tissue and
nerves.
-clitoris like penis is very sensitive to touch, stimulation and temperature and can
become erect.
PERINEUM - short stretch of skin starting at the bottom of the vulva and extending at
the anus.
URETHRA it is the passage of urine located at the pelvic cavity above bladder.
ENDOMETRIUM the innermost layer of uterine wall. Contains gland that bathe the
uterine lining.
A. COMPLETE DIAGNOSIS
PREGNANCY period of time between fertilization of the ovum (conception) and birth,
during which mammals carry their developing young in the uterus. The duration of
pregnancy in humans is about 280 days, equal to nine calendar months. After the
fertilized is implanted in the uterus, rapid changes occurs in the reproductive organs of
mother. The uterus becomes larger and more flexible, enlargement of the breasts
begins, and alteration of renal function, blood volume and blood cell count occur.
Movement of the fetus and fetal heartbeat can be detected early in pregnancy.
Reference: www.dictionary.com
HUMAN PREGNANCY divided into three trimester periods, as means to simplify
reference to the different stages of fetal development. The first trimester carries the
highest risk of miscarriage. During the second trimester the development of the fetus
can start to be monitored and diagnosed. The third trimester often remarks the
beginning of viability, or the ability of the fetus to survive or without medical help, outside
the mothers womb.
Reference: Mittenporf R. Williams MA, Berkeley CS Cotter PF. The length of
uncomplicated human gestation, OB Stet Gynesol 1990
PREGNANCY pregnancy brings both psychological and physical changes to the
woman and her partner. The physiologic changes of pregnancy occur gradually but
eventually affect all organ systems of the womans body. Psychological changes occur
in response not only to the physiologic alterations that are occurring but also to the
increased responsibility associated with welcoming new and completely dependent
person to the family. The changes occur in order for the woman to provide oxygen and
nutrients for the growing fetus, as well as extra nutrients for her own increased
increased metabolism during the pregnancy. They ready her body for labor and birth
and for lactation once the baby is born.
Reference: Maternal and Child Health Nursing, Adele Pillitteri
LABOR is the series of events by which uterine contractions and abdominal pressure
expel the fetus and placenta from the womans body. Regular contractions cause
progressive dilatation of the cervix and sufficient muscular force to allow the baby to be
pushed to the outside.
Reference: Maternal and Child Health Nursing, Adele Pillitteri
THEORIES OF LABOR ONSET
Rupture of membranes
5.4.Vaginal orifice / introitus occupies the lower portion of the vestibule and
varies considerably in size and shape. The vagina has an abundantly
vascular supply. Its upper third is supplied by the of the vesicovaginal
branches uterine arteries. Its middle third by the inferior vesical arteries. Its
lower third by the middle hemorrhoidal internal pudendal arteries.
Anteriorly, the vagina is in contact with the bladder and urethra from which is
separated by a connective tissue referred to vesicovaginal septum. Posteriorly
between the lower portion and the rectum is the rectovaginal septum.
Approximately, the upper of the vagina is separated from the rectum by the
rectouterine or cul-de-sac of Douglas.
The vagina varies in length. The anterior and posterior vaginal walls commonly
measure 6 8 cm. and 7 10 cm. in length, respectively. The areas around the
cervix at the upper end of the vagina are called fornicles, right and left, anterior
and posterior. The walls are lined with mucous membrane, which falls into folds,
or corrugated formation called rugae. These are referred to the inner wall of
vagina. It is smooth during labor and parturition. It is not present before
menarche and gradually become obliterated after repeated childbirth and
menopause. A healthy vagina has pH of 4.0 6.0.
Functions:
a. serves as excretory duct of the uterus
b. female organ for copulation
c. part of birth canal
Hymen comprised mainly of connective tissue both elastic and collagen. Both
surfaces are covered by stratified squamous epithelium. The hymen can be
broken through strenous physical activities or masturbation. After childbirth,
especially in multipara, the remnants of the hymen from several cicatrized
nodules of varying size called myrtiform caruncles.
6. Perineum the area extending from the fourchette to the anus. The pelvic and
urogenital diaphragm provides most of the support of the perineum.
6.1.Pelvic diaphragm consists of the levator ani muscles which is the
principal
muscle that is close to vagina and the coccygeus muscle posteriorly.
The levator ani muscles form a broad muscular sling that originates from
the posterior surface of the superior rami of the pubis, from the inner surface
of the ischial spine and between the 2 sites from the obturator rami.
The pubococcygeus and puborectalis constrict the vagina and rectum and
form an efficient functional rectal sphincter. Their functions are as follows:
Symptoms
Rationale
Justification
Remarks
Predisposing factors
Sex : Female
Patient is a female.
Present
Patient is now 22
years old.
Present
Precipitating factors
Coitus
Fertility
Intercourse allows
Patient had coitus
the delivery of the
with her husband.
sperm into the
cervical canal and
travels to the
fallopian tube
(isthmus) to meet
the egg and be
fertilized.
During fertile days,
Patient had sexual
there is a release
intercourse with her
mature of ovum and partner during fertile
is proliferation on
days.
the basal area of
the uterine lining
wherein theres
sufficient amount of
blood and is
suitable for fetal
growth.
C. ETIOLOGY
Present
Present
C. SYMPTOMATOLOGY
Symptoms
White vaginal
discharge
Rationale
Under in the influence of estrogen, the
vaginal epithelium and underlying tissues
Justification
Patient
reported that
Remarks
Present
she
experienced
having white
vaginal
discharge
during her
pregnancy.
Breast changes
Nausea and
Vomiting
Patient
verbalized
absence of
menstruation
last March 5,
2012.
Present
Pt. experienced
having breast
changes, oo
daw mas
nagdako kag
nag itom as
verbalized by
the patient.
Present
Patient
admitted that
she
experienced
Present
Urinary
Frequency
Constipation
Quickening
nausea and
vomiting during
her first month
of pregnancy.
Patient
admitted
frequency in
urination during
her first
trimester, huo
daw tong sa
ikadalawa ko
kag ikatlo nga
pagbuntis sigi
ko ka ihi2x.
Present
Patient
experienced
difficulty
constipation,
daw tong mga
7 months nagumpisa na
budlayan ko
magtae as
verbalized by
the pt.
Present
Pt. verbalized
that she
experienced
fetal
movements,
daw mga 5
months ata ko
Present
mabatyagan ko
nagasipa ang
bata as
verbalized by
the pt.
Patient has
stretch marks
on her
abdomen.
Present
Varicosities
Lightening
Patient armpit
and inguinal
areas becomes
more dark than
before and she
confirmed that
she has linea
nigra, huo may
ara ngalinya
nga iton diri sa
tiyan ko.
Patient had a
visible varicose
on the
popliteal.
Patient denied
feeling of
lessened
breathing
Present
Present
Not Present
Pain
difficulty or
feeling of
lightening,
wala man,
daw amo man
lang gyapon
as the pt.
verbalized.
Patient
admitted
release of pink
or bloody
mucus from the
vagina.
Present
Patient
admitted
perception of
mild pain but
not that
frequent,
masakit gaabot
abot, kagaina
medyo kis-a2x
pa, subong ga
sigi2x na.
Present
VII. HEMATOLOGY
Complete Blood Count - The complete blood count (CBC) is one of the most commonly ordered blood
tests. The complete blood count is the calculation of the cellular (formed elements) of blood. These
calculations are generally determined by special machines that analyze the different components of blood
in less than a minute. A major portion of the complete blood count is the measure of the concentration of
white blood cells, red blood cells, and platelets in the blood.
Laboratory
Result
NormalValue
Indication
Nursing Responsibility
Hemoglobin mass
111
120-160
Decrease
Hematocrit
0.34
0.40-0.50
Segmenter
0.73
0.55-0.60
Decrease:
Hemorrhage,
Anemia
Increase
may
indicate infection.
Lymphocyte
0.20
0.35-0.40
Decreasemay
follow infection
V 0.35
0.36-0.40
Decrease rate of
red
blood
cell
production.
To
know
the
patients
blood
type so that in
case
of
blood
transfusion due to
increase
blood
loss upon delivery.
Erythrocyte
Fraction
Blood type
DOCTORS ORDER
Time and
Date
December
12, 2012 @
2: 30am
ORDER
RATIONALE
REMARKS
*Please admit
The patient
was
admitted.
*NPO
~ This is done to
maintain the fluid and
electrolytes balance of
the patient as well as it
will serve as the partial
for IVTT medicine and it
is regulated at 20
gtts/min to prevent
toxicity and circulatory
overload.
The patient
was
monitored.
The patient
was
instructed.
IV fluid was
hooked
Laboratory
Labs:
CBC, BLD
TYPING
~These laboratory
examination was
ordered by the physician
to determine and role
out the condition of the
patient.
~Prevent infection
Cefalexin 500 g 1 cap
* 1 week
examination
was ordered
Medication
given.
Pt & V/S
monitored
as ordered.
Referred
XIII.PROGNOSIS
Prognosis
Good
Fair
Poor
Onset of Illness
Justification
-
Duration of
Illness
Hygiene
Diet
Age
Patient experience
labor pain 8 hours
prior to admittion.
She suffers irregular
pain. She does some
walking and rubbing
of the back to relieve
the pain. When she
went to the hospital ,
the pain continous
but it stops
sometimes.
Patient suffered labor
pain every2-3 mins.,
she can tolerate the
pain with the use of
depth breathing
exercise after the
contraction to ease
the pain.
Patient cannot do
personal hygiene
without any support
from family members
because she is a little
bet weak.
Patient how to
balance diet, she
have her meal on
time. She usually eat
fruits and drinking
fruit juices.
Patient is a 22 years
old and she is on 1st
time of delivery. She
dont have any
complication felt
during pregnancy but
Performance
Level
Willingness to
udergo
treatment
Family support
6/8
1/8
1/8
Remarks:
Prognosis shows, the patient condition in getting well is good, because most of
the criteria have good remarks. In this prognosis the pt will recover faster and regain her
strength in short duration of time, with the full support of her family.
XIV. BIBLIOGRAPHY
3. Nursing Care Plans / Guidelines for Individualizing Patient Care, 6th Edition /
Marilynn E.
Doenges, Mary Frances Moorhouse, Alice C. Geissler-Murr
4. Maternal & Child Nursing 2nd Edition / Emily Slone McKinney,Susan Rowena
James,
Sharon Smith Murray, Jean Weiler Ashwill
5. Maternal & Child Health Nursing / Care of the Childbearing & Childrearing By
Adele
Pilliteri